Does the crafted abdominal fat grafting technique completely eliminate risk of postoperative CSF leak in endonasal pituitary surgery? Technical note and preliminary clinical outcome.

Abstract

Objective: The endonasal transsphenoidal approach (ETA) developed over the years has become the standard of care for sellar and parasellar lesions. However, because it necessitates the removal of the skull base bone, it is often accompanied by CSF leakage. The authors aimed to provide technical nuances and analyze the results of their routine fat grafting technique after ETA.

Methods: A consecutive patient cohort (2004-2024) of 168 patients who underwent ETA for sellar and parasellar lesions and the modified fat grafting technique for skull base repair were retrospectively reviewed.

Results: Overall, combined ETA and transcranial approach (TCA) was performed in 7 (4.2%) patients, and 4 (2.4%) patients had prior transsphenoidal surgery. The size of the lesion was < 10 mm in 24 (14.3%) patients, 10-30 mm in 93 (55.4%), and > 30 mm in 51 (30.4%). Histopathological diagnoses were as follows: 154 (91.7%) pituitary adenomas, of which 45 (26.8%) were secreting; 8 (4.8%) Rathke's cleft cysts; 2 (1.2%) inflammatory/autoimmune lesions; 2 (1.2%) craniopharyngiomas; 1 (0.6%) renal cell carcinoma metastasis; and 1 (0.6%) chordoma. Gross-total resection was achieved in 127 (75.6%) patients, near-total resection in 22 (13.1%), and subtotal resection/partial resection/biopsy in 19 (11.3%). Overall, 122 (72.6%) procedures had intraoperative CSF leakage. Postoperative CSF leakage was observed in 1 (0.6%) patient treated with a revision operation and regrafting with a slightly larger graft and lumbar drainage.

Conclusions: Even slight modifications in contemporary surgical techniques and the addition of an innovative approach may improve the treatment of sellar and parasellar lesions via ETA and reduce the risk of CSF leakage. The authors have developed and described a modified fat grafting technique with gradual crafting and preprocessing of the abdominal fat tissue for skull base repair, and they have demonstrated its effectiveness in significantly reducing the CSF leak rate. This technique enables adequate reconstruction of skull base defects with low donor-site complication rates and obviates the need for external lumbar drainage.